Playing Poker with Health Reform

The National Journal’s December 5th issue has a very interesting article comparing President Obama’s approach to key issues to his poker playing style. (The issue cover states, “Obama as Poker Player.”)

Having played poker for over 45 years, I find the article’s discussion of his cautious approach and preference for standard games very enlightening. For many people today, poker is about Texas Hold’em, a game that is great for TV but rather simplistic in some ways because each player only has 2 cards and shares 5 others. The National Journal discusses the intellectual, strategic, and personality difference between this game, and more sophisticated games such as five-card draw and seven card stud – as well as more “wild” games such as baseball, although it doesn’t mention my crazed favorite, midnight baseball.…

End of the Beginning for Health Reform

November 29, 2009 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform, Politics, State-Level Healthcare Reform / No Comments

This week’s Economist has an article titled “The beginning of the end” about the coming Senate debate. But I think they have it exactly wrong. The passage of legislation through the Senate – and then ultimately through a Conference Committee and by both houses so it can be signed by the President – would be the end of the beginning for health reform.

In contrast to the many, many hours of work by Members of Congress, many more by their staff, and probably even more by interest groups and activists across the country, the implementation of a new set of laws will be the real beginning. …

Morphing Medical Homes into Advanced Primary Care Model

October 18, 2009 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform, State-Level Healthcare Reform / 4 Comments

The concept of patient centered medical homes (PCMH) has been evolving since it was first presented by 4 primary care medical societies, (AAFP, AAP, ACP & AOA), in March 2007. Since then, the PCMH concept has been endorsed by many other medical societies and interest in PCMHs has grown. Some of the significant steps forward have included:

The National Committee for Quality Assurance (NCQA) created specific requirements and a certification procedure for PCMHs
Several states are moving forward with PCMH pilot projects
Congress passed a law for Medicare Demonstration projects and the Department of Health and Human Services created draft guidelines for these projects – however, these guidelines haven’t been finalized although the demonstrations were scheduled to start in 2010

Steps Sideways
Along with all the interest and activity related to medical homes, there has been a blurring of the definition about what constitutes a medical home. …

Real Health Reform in Massachusetts

July 29, 2009 / Michael D. Miller MD / Delivery of Healthcare, Federal Healthcare Reform, Health System Reform, Quality of Care & Safety, State-Level Healthcare Reform / 5 Comments

The Massachusetts Special Commission on Payment Reform recently issued its recommendations for shifting the state’s health care system from Fee-For-Service (FFS) to Global Payments over a 5 year period. The Special Commission’s report lays out a good case for making this change, describing why it needs to be adopted by all payers, (although each payer would still pay different rates, they would all use the same fundamental global payment structure), and some of the challenges for successfully navigating a 5 year transition period from the current mostly FFS system to one dominated by global payments.

The report summarizes its recommendations into 9 areas:

The development of Accountable Care Organizations (ACOs).

…

Health Reform Hiatus – or Not

June 28, 2009 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform, State-Level Healthcare Reform / No Comments

I’ve been reading so much about health reform that the inside of my eyelids are burning with headlines about draft committee bills, CBO scoring, Republican responses, editorials for and against various amorphous proposals, and multiple organizations advocating about a public plan option, a public plan option, a public plan option…….

I was hoping that for the July 4th Congressional recess week the public’s and pundits’ attention would go elsewhere, but then I saw this week’s Economist cover picture of President Obama. (If you look closely you can see that the syringe is graduated in Trillions of dollars from $0.25trn to $1.5trn – indicating that paying for health reform is likely to be the main cause for political pain.)…

Culture of Health Reform

April 13, 2009 / Michael D. Miller MD / Access to Healthcare, Economics & Financing, Federal Healthcare Reform, Politics, State-Level Healthcare Reform / 2 Comments

One of the challenges for health reform legislation is the culture of the policy and political community.

Massachusetts’ insurance and coverage initiatives have been cited as lessons for health reform at the Federal level and other states. However, while observing a meeting of the state’s Special Commission on the Health Care Payment System last Friday, I was struck by how the culture of this group was very different than what I have often seen in Federal processes or within other states.

The Commission had agreed at their previous meeting that global payments should replace fee-for-service as the main payment route for medical services and products. …

3 Months Late – Massachusetts Waiver Extended

October 1, 2008 / Michael D. Miller MD / Access to Healthcare, Economics & Financing, Medicaid, State-Level Healthcare Reform / No Comments

Just a quick FYI – Today’s Boston Globe reports that the Federal Government has approved a new 3 year Medicaid demonstration waiver for Massachusetts – with $10.6 billion to enable the continuation and growth of the state’s health insurance coverage expansion program. The original 3 year waiver expired at the end of June, and the state and Federal officials had been discussing a new 3 year waiver for many months before that deadline. Since the end of June, the state’s program has been running on a series of several week extensions to the old waiver granted by the Federal Government.…

ERISA: The Unbridged Chasm of Health Reform – Challenges for Massachusetts and Federal Action

September 9, 2008 / Michael D. Miller MD / ERISA, Federal Healthcare Reform, Health System Reform, Politics, State-Level Healthcare Reform / 2 Comments

A recent Boston Globe article about a possible legal challenge to Masschusetts’ health reform initiative indirectly raised one of the most stubborn challenges in health reform: The Federal ERISA law. (See below for more about ERISA.)

The contentious issue in Massachusetts is a proposal to require employers to both pay at least 33% of full time employees’ health insurance premiums and ensure that at least 25% of their employees are covered by their health plan. (The current requirement is that they do one or the other.) So why should this difference be the basis for a law suit? Actually, there isn’t really any legal difference. …

The Face of Free Government Health Care

June 30, 2008 / Michael D. Miller MD / Economics & Financing, Medicaid, Miscellaneous, Politics, State-Level Healthcare Reform / No Comments

A couple of months ago I wrote about how one percent of adults in the US get free government health care. While the statistics in the February Pew study were very interesting (and somewhat shocking), I saw a report in a local Connecticut newspaper (The Day, June 26th) that put a face on these statistics.

The Day’s story was about Jihad Abdulshaheed, a 36-year-old man who had been incarcerated since November 2007. The judge was prepared to sentence to a one year sentence, and since he had already served at least 50% of his time, under the Department of Corrections guidelines for nonviolent prisoners he could have been released the next day.…

A Perfect Stormy Mess for Health Reform

April 15, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Federal Healthcare Reform, Health System Reform, Medicaid, Politics, State-Level Healthcare Reform / 4 Comments

A year ago the hype in healthcare was about state-based reform initiatives. Massachusetts was implementing its law, and several other states – including California – were considering their own proposals for increasing insurance coverage as a first step towards universal coverage and cost containment.

How things have changed in a year. Not only has California’s initiative crumbled under the expected costs to employers, but the economic downturn has undercut states’ healthcare expansion ideas, and may force them to cut back Medicaid enrollment and/or services. This week’s National Journal has an article titled “State’s Rapidly Shifting Gears,” that discusses these and other issues, including how a few years ago states cut their Medicaid payments to providers, so that on average Medicaid pays physicians 69% of Medicare levels, and how pending Federal Medicaid rules and proposals would reduce funding for State Medicaid programs making it difficult for states to reverse these payment reductions.…

NPR Story on Presidential Candidates’ Health Plans

February 22, 2008 / Michael D. Miller MD / Access to Healthcare, Economics & Financing, Federal Healthcare Reform, Politics, State-Level Healthcare Reform / 2 Comments

I caught part of the report on NPR this morning about the Presidential candidates’ positions on healthcare. The gist of the story was that Clinton favors more extensive individual mandates than Obama (who only favors mandates to cover children), while McCain favors tax credits to make health insurance more affordable.

Whoever becomes the next President, something will clearly be different starting in 2009. Regardless of the candidates’ campaign/political statements, the next President’s actions on healthcare (unlike in foreign affairs), will largely depend on what they can negotiate with the next Congress – which seems like it will be more Democratic than it is currently, but probably not with 60 Senators to force votes on matters that the minority finds objectionable.…

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